Basic Information
| Provider Information | |||||||||
| NPI: | 1861402547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CAC-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 MADSEN DR | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484628430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487937055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6500 | PA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 2-00998 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.